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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 13  |  Issue : 4  |  Page : 300-302

Mediastinal tuberculous abscess: A rare presentation after renal transplant


1 Department of Nephrology and Renal Transplant, AMRI Hospitals, Bhubaneswar, Odisha, India
2 Department of Transplant and Renal Sciences, AMRI Hospitals, Bhubaneswar, Odisha, India
3 Department of Radiology, AMRI Hospitals, Bhubaneswar, Odisha, India
4 Department of Pulmonology, AMRI Hospitals, Bhubaneswar, Odisha, India

Date of Submission17-Aug-2019
Date of Acceptance26-Nov-2019
Date of Web Publication31-Dec-2019

Correspondence Address:
Dr. Sukanto K Das
Department of Nephrology and Renal Transplant, AMRI Hospitals, Bhubaneswar, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_36_19

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  Abstract 


Despite successful renal transplantation, the risk of opportunistic infections posttransplant is a major concern. Cases of mediastinal tuberculous abscess are rare with nonspecific presentation. Here, we describe the case of a 55-year-old renal transplant recipient with complaints of fever, recurrent hiccups, and generalized weakness. Moreover, only after high-resolution computed tomography and microbiological examination of the aspirate of the abscess fluid, the diagnosis was confirmed as mediastinal tuberculosis (TB) with abscess formation. The use of immunosuppressants was the probable risk factor. Thus, a keen observation along with a high degree of suspicion should be kept to diagnose and thereby reduce the morbidity and mortality due to mediastinal TB in posttransplant recipients.

Keywords: Immunosuppression, mycophenolate mofetil, tacrolimus


How to cite this article:
Das SK, Das SK, Jena M, Kundu P, Behera S. Mediastinal tuberculous abscess: A rare presentation after renal transplant. Indian J Transplant 2019;13:300-2

How to cite this URL:
Das SK, Das SK, Jena M, Kundu P, Behera S. Mediastinal tuberculous abscess: A rare presentation after renal transplant. Indian J Transplant [serial online] 2019 [cited 2020 Apr 8];13:300-2. Available from: http://www.ijtonline.in/text.asp?2019/13/4/300/274609




  Introduction Top


Mediastinal tuberculosis (TB) is an extrapulmonary TB involving the mediastinal lymph nodes. Its incidence in adults is relatively rare, and in a renal transplant (RT) recipient, it has been rarely reported. The use of immunosuppressants could be the major predisposing factor responsible for the reactivation of the disease. Depending on the location and size of the growth, it might cause compression of the esophagus or trachea. Tuberculous abscess of the mediastinum can manifest with disseminated disease in patients receiving immunosuppressants. For diagnosis, one needs invasive techniques such as lymph node biopsy or aspirate drainage along with microbiological examination for confirmation of the bacilli. Early detection helps in early management which could prevent complications. In this article, we report such a rare case of tuberculous abscess in superior mediastinum in a renal allograft recipient.


  Case Report Top


A 55-year-old male patient was hospitalized in August 2018 for the symptoms of persistent fever, recurrent hiccups, episodes of vomiting, and generalized weakness. No history of chest pain, breathlessness, or hemoptysis was noted. The patient had received a renal allograft in September 2017 and was on triple-drug immunosuppression (prednisone, tacrolimus, and mycophenolate mofetil). The renal function was normal with baseline serum creatinine at around 0.9 mg/dl.

The physical examination on admission revealed tachypnea (30 breaths/min), with a blood pressure of 156/84 mmHg and pulse rate of 88 beats/min. Hemoglobin was 10.2 g/dL, and the total leukocytes count was 12,400/mm3. The X-ray chest did not show any major findings. Hence, the patient was started on empirical broad-spectrum antibiotic therapy (sulbactam and cefoperazone). There was some initial improvement but fever and hiccups persisted. Upper gastrointestinal endoscopy showed a few gastric erosions. A high-resolution computed tomography (HRCT) of the thorax was performed, which was suggestive of the loculated collection in the superior mediastinum in the perivascular space extending to lower neck and retrotracheal region crossing midline, compressing trachea and esophagus toward the right side [Figure 1]. There is minimal bilateral pleural effusion with basal peripheral consolidation of lower lobes. Ultrasound-guided aspiration of the abscess fluid was performed, and its microbiological examination revealed the presence of acid-fast bacilli (AFB) confirming the diagnosis of TB of the mediastinum. The patient was started on standard anti-tuberculous treatment, with standard four-drug regimen: isoniazid, rifampicin, pyrazinamide, and ethambutol. The tacrolimus level and renal functions were closely monitored during this time.
Figure 1: High-resolution computed tomography loculated collection in the superior mediastinum. Arrow showing abscess in the superior mediastinum in the perivascular space extending to the lower neck retrotracheal region crossing midline; compressing esophagus and trachea; and displacing toward the right side

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A repeat CT scan after a month was suggestive of two small nodular opacities in the anterior segment of the upper lobe and an apical segment of a lower lobe on the right side is likely infective [Figure 2]. These findings were suggestive of resolving infective lesion.
Figure 2: Repeat high-resolution computed tomography after treatment showing improvement.Arrow showing mediastinal fat stranding in the perivascular space in the superior mediastinum suggestive of resolving infective lesion

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  Discussion Top


The incidence of opportunistic infections such as TB is greater in recipients with RT as compared to the general population.[1] There are several risk factors favoring this, such as posttransplant use of immunosuppressants, longer duration of dialysis before the transplant, history of TB, malnutrition, endemic areas, and lower socioeconomic strata.[2]

The mode of contamination in such cases is through direct contact with patient active TB or reactivation of latent infection or transmission by the kidney received from the donor. The renal transplant recipients are usually on end-stage renal disease requiring dialysis for a long duration. These patients are more susceptible to TB as the uremic condition may affect phagocytosis. TB can affect any part of the body; however, mediastinal TB is a relatively rare condition in postrenal transplant recipients. It is the infection and abscess formation of the mediastinal fatty tissue. It may occur as a complication of pulmonary TB or as a primary infection in itself. The clinical manifestations are nonspecific, with fever, cough, occasionally hemoptysis, dyspnea, dysphasia, stridor, or symptoms due to mechanical compression caused by the lymphadenopathy.[3] As was seen in the above case, the patient had hiccups and vomiting, which could be due to compression or irritation to the phrenic nerve due to the abscess. It has been seen that though extrapulmonary TB is often seen in patients with renal transplant, however presentation with abscess is very rare. In a previous case, a 51-year-old male presented with acute thyroid abscess.[4]

In transplant recipients, immunosuppression impairs the T-cell-mediated immune function which facilitates opportunistic infections such as Mycobacterium TB.[5] Even the type and potency of immunosuppressants used have an association in the prevalence of TB. Same was being reported in a study by Atasever et al., where 4.5% of the patients developed posttransplant TB, out of which 6.1% were on the standard triple-drug immunosuppressive regime (tacrolimus, mycophenolate mofetil, or both) as compared to 4% of the two-drug regime (prednisolone and azathioprine).[6] This study also showed that intense immunosuppression with the triple-drug regimen had a higher frequency of developing TB during the initial 6 months posttransplant as compared to the two-drug regimen. However, in our case, the TB developed after a year of the transplant, which could be due to the mediastinal location, wherein the clinical presentation was nonspecific, and only on compression of the esophagus due to the increase in the size of the mass the symptoms developed.

Aggressive investigations are needed in cases of mediastinal TB, as radiological findings could be normal in some cases depending on the site and size of the nodes. In such cases, HRCT of the thorax guides the exact location and type of mass. The mediastinal abscess may mimic a sarcoma or metastatic mass. Hence, bacterial culture of the aspirate from bronchoalveolar lavage might be diagnostic. In our patient, an ultrasound-guided aspiration of the abscess fluid showed the presence of AFB confirming the presence of mediastinal TB.

The management of mediastinal TB in RT recipient is similar to the general TB cases. However, it should be monitored with caution as these drugs are known to have a drug interaction with immunosuppressive drugs.


  Conclusion Top


The clinical manifestation of mediastinal TB may be different in RT recipient as compared to the general population. Various investigations should be conducted for the accurate diagnosis of such cases. Even the treatment of TB must be monitored carefully considering the drug toxicity and interactions. Pretransplantation parameters that could probably predict the development of TB in these patients would be considered extremely crucial.



Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are nao conflicts of interest.



 
  References Top

1.
García-Goez JF, Linares L, Benito N, Cervera C, Cofán F, Ricart MJ, et al. Tuberculosis in solid organ transplant recipients at a tertiary hospital in the last 20 years in Barcelona, Spain. Transplant Proc 2009;41:2268-70.  Back to cited text no. 1
    
2.
Kaaroud H, Beji S, Boubaker K, Abderrahim E, Ben Hamida F, Ben Abdallah T, et al. Tuberculosis after renal transplantation. Transplant Proc 2007;39:1012-3.  Back to cited text no. 2
    
3.
Equi A, Redington A, Rosenthal M, Taylor GM, Jaswon M, Bush A. Pulmonary artery occlusion from tuberculous lymphadenopathy in a child. Pediatr Pulmonol 2001;31:311-3.  Back to cited text no. 3
    
4.
Engineer DP, Prakash S, Yadav A, Kumhar J, Biswas A, Kunal G, et al. Acute thyroid swelling in renal transplant recipient. Indian J Nephrol 2017;27:462-4.  Back to cited text no. 4
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5.
Boubaker K, Gargah T, Abderrahim E, Abdallah TB, Kheder A. Mycobacterium tuberculosis infection following kidney transplantation. Biomed Res Int 2013;2013:347103.  Back to cited text no. 5
    
6.
Atasever A, Bacakoglu F, Toz H, Basoglu OK, Duman S, Basak K, et al. Tuberculosis in renal transplant recipients on various immunosuppressive regimens. Nephrol Dial Transplant 2005;20:797-802.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2]


This article has been cited by
1 Mycophenolate mofetil/prednisone/tacrolimus
Reactions Weekly. 2020; 1790(1): 167
[Pubmed] | [DOI]



 

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